Claims Review Nurse (CERT)

This position provides support for a federal government project to review Medicare documentation as part of the Centers for Medicare & Medicaid Services’ (CMS) Comprehensive Error Rate Testing (CERT) program to measure improper payments in the Medicare fee-for-service (FFS) program.

• Full-Time, Monday – Friday
• Two open positions located in Richmond, Virginia

Responsibilities:

• Review claim documentation and associated medical records related to the CMS CERT program and determine whether Medicare FFS program services qualify for coverage and payment.
• Assess whether claim documentation and associated medical records complies with Medicare coverage, coding and billing rules.
• Compare documentation assessments to those of the Medicare contractor who originally reviewed and paid the claims and note which claims are in “error” if they have been incorrectly billed, paid or processed the services.

• Other duties as assigned

• Registered Nurse (RN) with an active license
• Associate’s, Diploma or Bachelor’s degree in Nursing
• 5 years of full-time work experience
• 3 to 5 years of experience in coding
• At least 2 years of experience in inpatient, acute care coding for Medicare reimbursement and MS-DRG experience
• Knowledge of standard coding conventions, such as DRGs, ICD-9-CM, HCPS and CPT
• Knowledge of Payment methodologies and Medicare guidelines
• Familiarity and understanding of Medicare rules, regulations, policies and procedures
• Familiar with Microsoft Word, Excel and Outlook
• Highly-motivated, detail-oriented, quick learner with a professional demeanor
• Ability to effectively work independently